SERC > SERC Workshop Module Template > Registration
Below you'll find an example of a workshop registration form. You'll want to work with SERC staff to develop an registration form appropriate for your workshop. You can download a .doc version (Microsoft Word 111kB Jul17 09) of this form to markup and use in communicating what you want for your form.

Confirmation deadline is ENTER DATE

For further information, contact INSERT COVENER EMAIL HERE
Please download the following medical and emergency information form, complete it, and bring it with you to the workshop in a sealed envelope. Medical Emergency Information Form

Complete the following form and click on SUBMIT to confirm your registration.

You must complete this form in one sitting; you cannot save a portion and return to fill out the rest later. We'd encourage you to compose your answers to the longer questions in a word processor and to cut and paste the resulting text into this form.

Be sure to click SUBMIT when you are done. Remember that you will not be able to alter your registration information via this form once you have submitted it, so please be sure you have completed all fields before submitting.
Participant Information

All uploaded files are public unless you are in a private workspace

Title: A descriptive, human readable title.

e.g. 'Student Handout for Sauerkraut Assignment'

Select the file: Make sure it has an appropriate suffix (e.g. .doc) or specify the type in the Optional Fields below

Description: A very brief description of the file.

File Type:

The system will attempt to determine the correct file type based on the name of the file you've selected. Choosing the correct file type here will override that.

File Name:

e.g. 'student_handout'
This will be the name of the downloaded file. By default the system will generate this based on the title you specified and the type of file. If you specify a name here it will over-ride the automatically generated name. This is generally only useful when uploading file of a type not recognized by the system (not in the list of file types above). In that situation choose File Type: Unknown Binary and include the appropriate suffix in the file name here. e.g. myfile.m3z Avoid spaces or special characters in the file names.


I am the author (copyright holder) of the contents of this file and people are allowed to reuse it for non-commercial purposes as long as they give me attribution as described by this creative commons license.
Who is the original creator/copyright holder of the information in this file?


A short description of where the material came from. Include names and institutions of authors and contributors as well as acknowledgment of any work from which this was derived.

Reuse License

The creator/copyright holder must have agreed to allow distribution of this file through this site.
If you are the creator we strongly encourage you to select the CC Attribution-NonCommercial-ShareAlike option.

If none of the above licenses apply describe the conditions under which this material appears on this site as well as any information about reuse beyond this site.

Distributing information on the web generally requires the permission of the copyright holder--usually the original creator. Providing the information we request here will help visitors to this site understand the ways in which they may (legally) use what they find.

If you created this file (and haven't signed away your copyright) then we'd encourage you to select the CC Attribution-NonCommercial-ShareAlike option. You'll retain the copyright to your file and can do as you please with it in the future. Through this choice you are also explicitly allowing others to reuse that file as long as they give you attribution, and don't use it for commercial purposes.

If the file (or content within it) was created by others you'll need their permission. If it predates 1923 or was created by a U.S federal employee (as part of their job) it is likely in the public domain (and we can all do as we choose with it). The original author may also have explicitly stated how it may be reused (e.g. through a creative commons license). You can describe the licensing/reuse situation in the box above.

Without permission you should not upload the file. There are several options in this case:

  • You can contact the original author to get permission.
  • You can provide a link to (or a description of how to get) the original material rather than uploading it here.
  • You can find a substitute that isn't encumbered by copyright.
  • You can create a substitute yourself. Remember, ideas can't be copyrighted, only particular expressions of those ideas. Of course you'll want to give credit the original author.

The Stanford Copyright and Fair Use Center has more good information about copyright as it applies to academic settings.

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you.)

Workshop Questions

Why are you interested in participating in this workshop? Check all that apply.


Incoming Flight Information

Outgoing Flight Information

Diet and Mobility Accommodations

Research ReleaseI have read the Description of the Research Project and Implications for Participation (opens in a new window) or it was read to me. I know the possible risks and benefits. I know that being in this study is voluntary. I choose to be in this study. I know that I can withdraw at any time. I am at least 18 years of age and voluntarily grant permission for the described release and use of notes and comments regarding me in the workshop.

Workshop Product ReleaseIn confirming my registration for this workshop, I agree that any audio recording or images (still or video) made of me during the workshop may be used on the project website, in printed project publications, and in materials developed by the project. I further agree that my contributions to creative works that emerge from workshop activities (e.g., discussions on the email list, contributions to the web page, summaries of group discussions, etc.) may be used by the workshop series, PIs, and conveners for development of future workshop materials, for scholarly reports, and for promotion of the workshop series. Attribution for original contributions will be made whenever possible.
I also accept responsibility to cover any costs incurred should I withdraw from participation in the workshop after DATE. I understand that arrangements have been made on my behalf that have associated real costs (e.g. logistics, materials), and in many cases, my early confirmation has secured a place that has been denied to other interested colleagues. Exceptions will only be made in cases of extreme personal hardship.
*Please type the two distorted words into the box below. Separate them with a space. This helps us prevent spam. For more details or help click the question mark.

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